Fill and Sign the Life Insurance or Annuity Contract Form

-1- RENUNCIATION AND DISCLAIMER OF PROPERTY (Life Insurance or Annuity Contract) I. Pursuant to the Iowa Code Chapter 633E, the undersigned, ______________________, has an interest in a life insurance policy and/or an annuity contract that he/she chooses to exercise his/her right to disclaim any interest in the policy and/or the contract. The identifying policy/contract information is as follows: ______________________ II. The undersigned has an interest in the property in the above-captioned policy/contract of ______________________ (the decedent) who died on ______________________. III. 1. I irrevocably and without qualification renounce, release, decline, disclaim and refuse to accept any and all rights or interest in and to the following specifically described property or property rights (the "disclaimed property"): _____________2. The disclaimed property was to pass to the Disclaimant pursuant to Article _____________ of the _____________ (name of decedent) Last Will and Testament which has been admitted to probate as above set forth.3. This Disclaimer is irrevocable and I waive and renounce any right to amend or revoke this Disclaimer in any manner. -2- 4. I have not accepted the disclaimed property or any interest in or benefits from the disclaimed property.5. I have not accepted or agreed or contracted to receive or accept any consideration in return for this Disclaimer.6. I was not insolvent as of the date of execution of this Disclaimer and have not been insolvent at any point in time since my rights in the disclaimed property were finally ascertained and indefeasibly forfeited.7. I have not voluntarily assigned or transferred or contracted to assign or transfer any interest in the disclaimed property or waived the right to disclaim such property.8. I have not sold or otherwise disposed of any interest in the disclaimed property or the disclaimed property has not been sold or otherwise disposed.9. I intend this Disclaimer to be a "Qualified Disclaimer" under the Internal Revenue Code Section 2518 and it shall be construed accordingly. IV. The undersigned is entitled to receive the following property:______________________ V. -3- The property devolves to others pursuant to the provisions of applicable State law as though the undersigned had predeceased the decedent. VI. Pursuant to applicable law of the State of Iowa, and the Internal Revenue Code of 1986, if applicable, the undersigned hereby renounces and disclaims any interest or right to the property or asset of the deceased described in paragraph IV. VII. This renunciation and disclaimer shall for all purposes be deemed to relate back to the date of decedent's death and is an irrevocable refusal to accept that property effected hereby, and is hereby delivered to the personal representative, executor or executrix of the decedent.DATED this ______ day of _____________, 20______. _______________________________________ Signature _____________ (Name) STATE OF IOWACOUNTY _____________ On this ______ day of _____________, ______, before me, a Notary Public, personally appeared _____________, to me known to be the person named in and who executed the foregoing instrument, and acknowledged that he/she/they executed the same as his/her/their voluntary act and deed. ______________________________Notary PublicPrint Name: _____________ -4- I certify that on the ______ day of _____________, 20______, I delivered a true copy of the Renunciation and Disclaimer of Property by personal delivery, registered mail, and/or certified mail to _____________ (name and address), the personal representative, executor, executrix, or other fiduciary of the decedent. DATED this the ______ day of _____________, 20_______. _________________________________Signature_____________Print Name_____________ Address _____________City, State, Zip Code_____________Telephone -5- Receipt of an executed copy of the above Renunciation and Disclaimer is acknowledged this ______ day of _____________________, 20______. _____________________________________ _____________________ (Name) Personal Representative/Executor/Executrix